Biological predictors of suicidality in schizophrenia

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65166/1/j.1600-0447.1996.tb09883.x.pd

Suicide risk in schizophrenia: learning from the past to change the future

Suicide is a major cause of death among patients with schizophrenia. Research indicates that at least 5–13% of schizophrenic patients die by suicide, and it is likely that the higher end of range is the most accurate estimate. There is almost total agreement that the schizophrenic patient who is more likely to commit suicide is young, male, white and never married, with good premorbid function, post-psychotic depression and a history of substance abuse and suicide attempts. Hopelessness, social isolation, hospitalization, deteriorating health after a high level of premorbid functioning, recent loss or rejection, limited external support, and family stress or instability are risk factors for suicide in patients with schizophrenia. Suicidal schizophrenics usually fear further mental deterioration, and they experience either excessive treatment dependence or loss of faith in treatment. Awareness of illness has been reported as a major issue among suicidal schizophrenic patients, yet some researchers argue that insight into the illness does not increase suicide risk. Protective factors play also an important role in assessing suicide risk and should also be carefully evaluated. The neurobiological perspective offers a new approach for understanding self-destructive behavior among patients with schizophrenia and may improve the accuracy of screening schizophrenics for suicide. Although, there is general consensus on the risk factors, accurate knowledge as well as early recognition of patients at risk is still lacking in everyday clinical practice. Better knowledge may help clinicians and caretakers to implement preventive measures. This review paper is the results of a joint effort between researchers in the field of suicide in schizophrenia. Each expert provided a brief essay on one specific aspect of the problem. This is the first attempt to present a consensus report as well as the development of a set of guidelines for reducing suicide risk among schizophenia patients

Understanding suicidal ideation in psychosis: findings from the Psychological Prevention of Relapse in Psychosis (PRP) Trial

Objective: To examine the clinically important phenomenon of suicidal ideation in psychosis in relation to affective processes and the multidimensional nature of hallucinations and delusions.Method: In a cross-sectional study of 290 individuals with psychosis, the associations between level of suicidal ideation, affective processes, positive symptoms, clinical and demographic variables were examined.Results: Forty-one per cent of participants expressed current suicidal ideation. Suicidal ideation was associated with depressed mood, anxiety, low self-esteem, negative illness perceptions, negative evaluative beliefs about the self and others and daily alcohol consumption. Frequency of auditory hallucinations and preoccupation with delusions were not associated with suicidal ideation; however, positive symptom distress did relate to suicidal thoughts.Conclusion: Affective dysfunction, including distress in response to hallucinations and delusions, was a key factor associated with suicidal ideation in individuals with psychotic relapse. Suicidal ideation in psychosis appears to be an understandable, mood-driven process, rather than being of irrational or 'psychotic' origin

The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness

Objectives. Poor adherence to medication treatment can have devastating consequences for patients with mental illness. The goal of this project was to develop recommendations for addressing adherence problems to improve patient outcomes. Methods. The editors identified important topics and questions concerning medication adherence problems in serious mental illness that are not fully addressed in the literature. A survey was developed containing 39 questions (521 options) asking about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41(85%) of the 48 experts to whom it was sent. Results of the literature review and survey were used to develop recommendations for assessing and improving adherence in patients with serious mental illness. Results. ASSESSING ADHERENCE: The experts endorsed percentage of medication not taken as the preferred method of defining adherence, with 80% or more of medication taken endorsed as an appropriate cut-off for adherence in bipolar disorder and schizophrenia. Although self- and physician report are the most common methods used to assess adherence in clinical settings, they are often inaccurate and may underestimate nonadherence. The experts recommend that, if possible, clinicians also use more objective measures (e.g., pill counts, pharmacy records, and, when appropriate, serum levels such as are used for lithium). Use of a validated self-report scale may help improve accuracy. SCOPE OF THE PROBLEM: The majority of the experts believed the average patient with schizophrenia or bipolar disorder in their practices takes only 51%-70% of prescribed medication. FACTORS ASSOCIATED WITH NONADHERENCE: The experts endorsed poor insight and lack of illness awareness, distress associated with specific side effects or a general fear of side effects, inadequate efficacy with persistent symptoms, and believing medications are no longer needed as the most important factors leading to adherence problems in schizophrenia and bipolar disorder. The experts considered weight gain a side effect that is very likely to lead to adherence problems in patients with schizophrenia and bipolar disorder; sedation was considered a more important contributor to adherence problems in bipolar disorder than schizophrenia. The experts rated persistent positive or negative symptoms in schizophrenia and persistent grandiosity and manic symptoms in bipolar disorder as the most important symptomatic contributors to adherence problems in these illnesses. INTERVENTIONS: It is important to identify the specific factors that may be contributing to a patient's adherence problems in order to customize interventions to target those problems. Multiple problems may be involved, requiring a combination of interventions. Conclusions. Adherence problems are complex and multi-determined. The experts recommended customized interventions focused on the underlying causes. Copyright © of content 2009 owned by Comprehensive Neuroscience, Inc

Racial and Ethnic Diagnostic Patterns in Schizophrenia Spectrum Disorders

The literature on racial and ethnic diagnostic patterns (as these pertain to schizophrenia spectrum disorders) is reviewed in this chapter. The chapter begins with a review of the literature on the diagnostic patterns among racial and ethnic minorities in the USA and abroad, followed by a review of racial/ethnic differences in symptom severity, symptom expression, and prevalence rates. This is then followed by a review of the empirical literature that offers explanations about why differential diagnostic patterns are observed. This review explores the question of whether differential patterns are due to inherent differences between racial/ethnic groups or if clinician biases and/or decision-making processes are contributing to differential diagnostic practices. Finally, literature that points to cultural mistrust, paranoia, and other environmental factors (e.g., stress) as potential variables that may contribute to the differential diagnostic patterns among racial/ethnic groups is reviewed. These reviews suggest that Black patients are three to four times more likely to receive a schizophrenia spectrum diagnosis. Findings also suggest that racial/ethnic variations may exist on a symptom level, with greater differences observed among positive symptom profiles. This review suggests that unawareness of cultural differences in symptom expression, cultural mistrust, and environmental factors (e.g., low SES) may be related to greater likelihood of receiving a schizophrenia spectrum diagnosis but do not fully account for the diagnostic discrepancies observed among racial/ethnic groups. To better understand these relationships, we conclude with recommendations to improve diagnostic accuracy and cultural competence (e.g., greater reliance on the Cultural Formulation Interview) and suggestions for future research that may further clarify the racial/ethnic diagnostic conundrum (e.g., using analog research studies)